Recordkeeping Is a Bridge, Not a Barrier

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Written by Ryane E. Englar, DVM, DABVP (canine and feline Practice)

In many veterinary schools—and even in some veterinary practices—medical documentation is seen as an obstacle: something that prevents us from getting home on time. Yet, written communication is an essential component of patient care. It serves as a record of what happened to the patient, when, and at whose fingertips. In this respect, written communication is the cornerstone of case management and continuity of care.

Judge Sheindlin, star of the reality court show Judge Judy, popularized the statement, “If you tell the truth, you don’t have to have a good memory.” This aphorism applies to medical documentation, too. Medical documentation keeps us honest. It is our opportunity to preserve our actions and statements as a legal record of patient care. Instead of seeing recordkeeping as a hurdle, think of it as a bridge. Medical records tell your story long after your memory fades, and they house essential data concerning:

  • Patient history and client concerns
  • Physical exam findings
  • Patient problem list and prioritization of differential diagnoses
  • Diagnostic test results and therapeutic plans
  • Diagnosis and prognosis
  • Case management decisions, along with their rationales
  • Your expectations (and the client’s) in terms of the patient’s response to treatment
  • Client communication, both during and after the consultation, including in-person and electronic correspondence as well as summaries of telephone conversations
  • Next steps including when to recheck as well as any other decision trees (e.g., if the patient vomits >2x in the next 24 hours, then reconsider diagnostic imaging of the abdomen and baseline bloodwork)

Variations of the phrase, “if it isn’t charted, it didn’t happen,”1 permeate the healthcare industry2-6—and with good reason. New graduates are most at risk of having a liability claim filed against them.7 And outcomes of board complaints rest on proof rather than the veterinarian’s recollection.8 Simply put, it pays to invest in documentation.

 Accurate, thorough documentation should include not only what happened and why, but also what didn’t happen (but should have) and actions taken to mitigate impact, including the details of what specifically was discussed with the client and agreed upon.

 In this edition of the AVMA Trust Student e-Newsletter, which describes a liability claim due to subcutaneous administration of an intranasal Bordetella bronchiseptica vaccination, the following key points would have been essential to include in the patient’s medical record:

  • The approved, on-label route(s) of administration, based upon the product insert, as well as the actual route of administration
  • Immediate after-care following the procedural error (e.g., dilution of injection site with saline)
  • A detailed description of how the procedural error was disclosed to the client: what information was shared by the veterinarian and support staff; which questions and/or concerns were raised by the client; and how the veterinary team addressed the client’s inquiries
  • Each subsequent client communication, including the veterinarian’s conveyed expectations to the client concerning the patient’s recovery and its anticipated timeline
  • Each follow-up conversation with the ER facility, including subsequent care interventions and the patient’s response to treatment

These details provide a written record of care that the insurance carrier and attorney(s) can reference to assess the viability of a given claim with respect to whether liability or fault can be established. It is critical to note that conversations between the veterinarian, the insurance carrier, and attorney are privileged information between the insured and their providers. Therefore, these details should be excluded from the medical record.

For additional information on medical documentation, specifically how to write SOAP notes in companion animal veterinary practice, complete with practical exercises and answer keys, please refer to Writing Skills for Veterinarians.9

 

References:

1Trossman S. The documentation dilemma: Nurses poised to address paperwork burden. The American Nurse. 2001; 33 (5): 1-18.

2Page, A. (Editor). Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington (DC), 2004.

3Nguyen A.V.T., & Nguyen D.A. Learning from Medical Errors: Legal Issues. Abingdon, United Kingdom: Radcliffe Publishing, Ltd.; 2005.

4Andrews, A., & St. Aubyn, B. 'If it's not written down; it didn't happen.' Journal of Community Nursing. 2015; 29(5): 20-2.

5Catalano, J. Nursing Now! Today's Issues, Tomorrow's Trends. Seventh ed. Philadelphia, PA: F.A. Davis Company; 2015.

6David, G. & Vinkhuyzen, E. Medical records' dynamic nature. If it isn't written down, it didn't happen. And if it is written down, it might not be what it seems. J AHIMA. 2013; 84(11): 32-5.

7Radford, A.D., Stockley, P., Taylor, I.R., Turner, R., Gaskell, C.J., Kaney, S., et al. Use of simulated clients in training veterinary undergraduates in communication skills. Vet Rec. 2003; 152(14): 422-7.

8Wilson, J.F. Law and ethics of the veterinary profession. Yardley, PA: Priority Press, Ltd.; 2000.

9Englar, R.E. Writing Skills for Veterinarians, 5m Publishing, February 2019, 1st edition, 261 pages.